Family

Applying for inpatient care benefits for a dependent person

Residents

Inpatient care is provided by establishments such as residential care and assistance facilities which include integrated centres for the elderly, nursing homes and intermittent stay establishments which are mainly active in the disability sector.

Persons who wish to benefit from long-term care insurance in order to benefit from inpatient care should send their application to the National Health Fund (Caisse nationale de santé - CNS).

When an individual is recognised as being a dependent person by the National Health Fund, they receive benefits in line with a care plan drawn up by the long-term care insurance's Administration for Evaluation and Controls (
Administration d'évaluation et de contrôle - AEC) itemising the care and support that is to be provided.

Who is concerned

Each person registered with the health insurance and their co-insured family members are entitled to long-term care insurance. Each person is entitled to long-term care insurance, regardless of income, provided they have been recognised as dependent.

Persons who take out voluntary health insurance must have been affiliated with their health insurance fund for at least one year.

Individuals registered with theNational Health Fund (CNS) who have been recognised as dependent persons, but who do not reside in Luxembourg (e.g., cross-border workers) have to contact the health fund in their country of residence in order to receive benefits in kind; such benefits are not exportable.

Persons affiliated with a health fund in another Member State of the European Union but residing in Luxembourg may be eligible for benefits in kind in Luxembourg if they are receiving treatment in a care and assistance facility.

Prerequisites

A person is deemed to be a dependent person if the following conditions are met:

a person who, owing to a physical, mental, psychiatric or similar illness, requires significant help and regular assistance from another person to carry out basic day-to-day tasks (actes essentiels de la vie - AEV);

basic day-to-day tasks refer to personal hygiene (e.g., bathing), assistance to go to the toilet, to eat, to dress and mobility issues;

the level of assistance needed to carry out basic day-to-day tasks must be of a certain level and represent at least 3 ½ hours of care per week in the aforementioned areas;

the need for assistance must be required for a minimum of 6 months or be permanent.

the medical report ( R20) attached to the second part of the form and completed by the applicant's general practitioner.

The medical report (R20) is free of charge for the applicant: the physician is paid directly by the long-term care insurance.

In this report which is for the attention of the Administration for Evaluation and Controls, the doctor provides information on the applicant's state of health. While the role of the doctor is important, they are not the ones who decide whether the person is dependent.

The application will only be considered complete when both documents (the form and the report) have been submitted to the National Health Fund (CNS).

A return receipt confirms receipt of the application.

Evaluation and determination of the assistance and care services required

The National Health Fund (CNS) forwards the application file to the Administration for Evaluation and Controls (AEC) of the long-term care insurance which is responsible for determining the dependence and to evaluate the level of dependence.

The evaluation of the state of dependence is performed by a health professional from the AEC, in the applicant's home, the premises of the AEC or the care and assistance facility. The applicant will be informed of the upcoming evaluation.

In principle, the health professional is responsible for the application file and also guarantees its follow up. Their contact details will be communicated to the applicant at the time of the evaluation.

During the evaluation, the dependent person's capacity to perform basic day-to-day tasks will be examined. The person applying for the benefits and a professional from the care facility will be asked questions.

After the evaluation, the health professional draws up a summary of the assistance and care services to which the dependent person is entitled during one week, which will then allow to see if the help required reaches the minimum of 3.5 hours/week for basic day-to-day tasks (AEV).

Communication of the decision to cover care services

The President of the National Health Fund (CNS) takes the decision based on the AEC's opinion. The decision is submitted, where applicable, together with the summary of assistance and care services that will be provided. Both the dependent person and the care and assistance facility providing the services will be informed of the decision.

The summary will inform the dependent person of:

the different services to which the dependent person is entitled (basic day-to-day tasks, measures to support the person's independence, support activities in the care and assistance facility);

the weekly amount of care and assistance services;

a detailed description of the services provided;

assistive technology devices granted following the evaluation.

The benefits will be granted at the earliest from the day the complete application is submitted.

Types of accommodation

There are 2 types of care and assistance facilities:

in inpatient care facilities, dependent persons are provided with day- and night-time accommodation as well as with all of the assistance and care they need;

semi-stationary care facilities (intermittent stay) are establishments that provide day- and night-time accommodation mostly for disabled people. In this type of facility, however, dependent persons may interrupt their stay—for an indeterminate period of time, and on a regular or irregular basis—in favour of accommodation in a private home. In this case, they are entitled to in-patient care benefits when they are staying in the facility and to the home-care benefits, when they are at home.

When a dependent person is staying in a care and assistance facility, the long-term care insurance covers benefits in kind and assistive technologies not provided by the establishment, but which may be required depending on the person's level of dependence, as defined in the summary of the assistance and care services of the long-term care insurance.

Accommodation costs (e.g., rent of the room and meals) are borne by the dependent person.

Conditions of placement

Assistance and care facilities manage admissions themselves. If a dependent person wishes to occupy a room in a facility, they must contact the establishment of their choice directly for information on waiting times for admission and, if applicable, to have their name placed on a waiting list.

A contract is then entered into between the 2 parties in which the facility undertakes to provide the care and assistance services required after the state of dependency was assessed.

As a result, all of the benefits in kind or assistance technologies itemised in the summary of the assistance and care services, as established by the long-term care insurance's Administration for Evaluation and Controls (AEC), are covered directly by the long-term care insurance.

In general, these are essential day-to-day tasks for purposes of personal hygiene, nutrition, dressing, assistance to go to the toilet and mobility assistance. Individual or group activities, as well as some assistive technologies, may also be covered.

Benefits in kind

The term 'benefits in kind' encompasses all aid and assistance provided by a professional service.

In the case of a stay in an in-patient setting, this type of benefit is provided by an assistance and care facility and is directly covered by long-term care insurance.

Assistive technologies

In principle, assistance and care facilities are obliged to provide devices that are part of their basic equipment.

However, long-term care insurance allows special devices to be obtained, provided that the person has a continuous and personal need for them, and that the assistive technologies are specifically adapted to the needs of the person concerned. If these devices are required, the AEC may grant the right to such assistive technology devices which are not provided by the care facility within the framework of the evaluation.

Combination with other benefits

Beneficiaries of long-term care benefits may not receive the following at the same time:

a health insurance benefit of the same nature (health insurance takes priority in this case, except for coverage of assistive technologies);

benefits of the same kind provided for by the accident insurance, the legislation relating to disabled persons or the differentiated education, all of which take priority where appropriate;

a housing benefit, which is suspended up to the amount covered by long-term care insurance for home adaptations. Costs exceeding the amount covered by the insurance may still be covered by the housing benefit.

Review of the file

If the degree of required assistance and care changes, the dependent person may request that their situation be re-evaluated. The re-evaluation may also be requested by:

family members;

care providers;

the CNS;

the AEC.

In principle, a re-evaluation can only be requested one year after the last decision, except if the medical report states that there has been a fundamental change in circumstances since then.

The person submits the request for re-evaluation with the same form used to submit an initial application.

When the new evaluation gives rise to an increase in benefits, this increase will, in theory, take effect on the first day of the week in which the application was submitted. If the benefits are reduced, the reduction will be effective on the first day of the week following notification of the decision to reduce the benefits.

Revocation of benefits

If the conditions that resulted in the benefits being granted disappear, long-term care insurance benefits will be discontinued.

Benefits paid in error must be repaid, notably when the beneficiary's situation changes without the long-term care insurance management body being notified.

Disputes

If the applicant does not agree with the CNS's initial decision, they may oppose it before the CNS's executive committee. To do so, they need only send a letter to the executive committee of the CNS within 40 days of the decision. The procedure is described in the decision that the person receives.

When the applicant lodges an opposition to the decision, their file is re-evaluated by the Administration for Evaluation and Controls (AEC) in order to assess the merits of the opposition.

If the applicant does not agree with the decision of the CNS's executive committee, they may file an appeal, within 40 days of receiving notification of the decision, with the Social Security Arbitration Tribunal (Conseil arbitral de la sécurité social - CASS) located in Luxembourg. A simple petition on plain paper submitted to the CASS will suffice.

CASS decisions can, themselves, be appealed if the amount in dispute is in excess of EUR 1,250. Applicants have to address the High Council of Social Security (Conseil supérieur de la sécurité sociale) within 40 days of the notification of each decision.